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Chapter 30
Bowel Elimination and Care
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Terminology Related to Bowel Elimination
Defecation: process of bowel elimination Constipation: hard stools; difficulty passing
stools Diarrhea: several liquid stools per day Fecal impaction: stool obstruction Flatus: gas
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Gastrointestinal (GI) Tract Mouth Anus Waste products—feces or stool Process of bowel elimination—defecation
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Peristalsis Consists of rhythmic wavelike movements
beginning in the esophagus and continuing to the rectum
Involves contraction of the circular and longitudinal muscles in the walls of the GI tract
Propels the bolus of food through the GI tract
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Process of Digestion, Absorption, and Metabolism of Nutrients
Bowel elimination occurs after nutrients are moved through the GI tract
In the stomach, enzymes break down the bolus of food, converting it to chyme
The chyme passes through the pyloric sphincter and into the small intestine, where the nutrients are absorbed
The remaining chyme passes through the illeocecal valve into the large intestine to be passed as stool
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Changes Through Life Cycle Infants—three to six bowel movements
(BM)/day Children—one to two/day Elderly—peristalsis slows—more prone to
constipation or hard stools that are difficult to pass
At least every three days
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Characteristics of Feces Color, shape, consistency, odor, and
frequency Diet, amount of fiber and fluids, exercise,
medications, and other habits Disease process can change characteristics Assessment is important
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Normal Soft, formed, light yellowish-brown to dark
brown, and slightly odiferous and slightly curved shape
Color—vary by dietary intake Spinach Beets Iron
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Abnormal Characteristics Table 30-1, pg. 678 Inadequate fluid intake Transit time Fiber Increased amount of fat Steatorrhea—fluffy, float, foul odor
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Abnormal Characteristics Malabsorption disease—Chron’s Ribbon-like stools Mucus , blood, or pus Parasites, worms, or eggs Clay colored or pale white stools Frank blood—visible to naked eye
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Abnormal Characteristics Occult blood—hidden blood All bleeding is considered serious until proven
otherwise Must be reported to physician
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Abnormal Characteristics of Stool Liquid, watery, unformed, hard, dry Balls, clumps, flat or ribbonlike, pencil-like Bright red blood, black, coffee-ground
appearance, pale, white, gray, or claylike Presence of pus or mucus; floating on water Presence of worms or eggs Foul odor, bloody, or metallic smell
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Factors Affecting Bowel Elimination Change in activity level Change in dietary intake Change in water source Change in fluid volume intake Side effects of medication Side effects of surgery Pregnancy
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Factors Affecting Bowel Elimination (cont.)
High stress levels and emotional problems
Laxative abuse Aging process Structural changes Chemical changes Food allergies
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Common Alterations in Bowel Elimination
Constipation Diarrhea Impaction Fecal incontinence
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Constipation Less frequent, hard, formed stools—difficult
to expel Bloated feeling Degrees of severity Impaction—blockage due to mass of very hard
stool
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Constipation Impaction
Loss of appetite Bloating Cramping Malaise Just not feeling well
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Constipation Possibly no complaints Always note when was patient’s last BM Assess elderly and those from long term care
setting for s/s of constipation or impaction
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Diarrhea Loose or watery stools occurring three or
more times/day Cramping—may or may not be present Monitor for possible complications
Excoriated perianal skin Dehydration and electrolyte imbalance Especially infants, young children, and elderly
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Fecal Impaction Rectum, sigmoid flexure, or any part of large
colon Elderly, inactive patient’s, severely dehydrated Common cause—abuse of laxatives Possible indication—liquid stool Complication—obstruction or perforation of
bowel
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Digital Removal of Impaction Can be embarrassing and painful Oil retention enema or pain med Prior to procedure
Delegate? Need an order? Review patient history—contraindications? Monitor for s/s of vagus nerve stimulation
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Fecal Incontinence Voluntary control is lost Beyond patient’s control
Spinal cord injury Disoriented patient’s
Source of guilt, embarrassment, and destruction of self-esteem
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Fecal Incontinence What can be done?
Bowel training Proper cleansing and barrier creams Fecal incontinence pouch Maintain patient’s dignity—never refer to as
diapers
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Bowel Elimination Assessment of BM and documentation
Color Amount Consistency Unusual shape Unusual odor
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Nursing Interventions to Promote Bowel Function
Increase physical activity Ensure adequate fluid: up to 2,500 mL/day Increase fiber intake to 20 to 30 g/day (gradually!!) Provide privacy Position patient upright for elimination Provide stimulants that “cue” bowel function at
home, such as a cup of hot coffee before breakfast
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Subjective Assessment On admission to hospital Subjective information of patient’s normal
bowel habits Any current problems with BM’s
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Objective Assessment Physical assessment
Shape of abdomen Normal—rounded or flat Abnormal—distended or inflated Distention—excessive gas, fluid, or stool
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Objective Assessment Auscultate bowel sounds
Diaphragm portion of stethoscope Listen in all four quadrants Once per shift or more often if indicated Soft gurgles or irregular clicks Between 5 and 30/minute
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Objective Assessment Bowel sounds
<5/minute—hypoactive bowel sounds >30/minute or continuous—hyperactive bowel
sounds May indicate obstruction—high pitched, tinkling
sounds in one area and absent or decreased sounds in the distal portion
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Objective Assessment An absence of bowel sounds indicates a
problem and should always be reported to the physician
To determine absent bowel sounds—listen 3 to 5 minutes in each quadrant
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Objective Assessment Assessment of abdomen
Inspection Auscultation Palpation
Palpation Normal—soft Abnormal—firm or hard—excessive gas, constipation,
or obstruction
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Importance of… Increased activity Adequate fluid intake Adequate fiber intake Privacy during elimination Positioning during elimination
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Management Universal precautions
Possibility of contact with feces Incontinent patient Emptying bedpan or bedside commode Removing an impaction Collecting stool specimen Administering enema Providing colostomy care
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Management Altering dietary intake related to diarrhea
Clear liquid diet first 24 hours Decaffeinated green or black teas or herbal tea Sports drinks—replace electrolytes Avoid extremely hot or cold liquids first 24 hours Longer than 24 to 36 °--full liquids and cooked
fruits or vegetables
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Management Diarrhea due to loss of normal flora—yogurt Concurrent use with antibiotics—prevent the
loss of normal flora
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Management Medications
Coat the mucous membranes of the bowel Inhibit peristalsis Treat the disease or infectious process
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Management Lactobacillus acidophilus
Supplement Replace normal flora
Medications for constipation Increase peristalsis Soften stool Add bulk to stool
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Management Enema
Instillation of solution into the colon via the rectum
Temperature—between 105 to 110° F—to avoid burning intestinal mucosa
Test—should feel warm, NOT HOT Too cool—cause cramping
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Management Position*
Left lateral side-lying or Sims’ Insert tip of tubing 3 to 4 inches (adult)
Rectum, sigmoid colon, and descending colon
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Management If a high enema is ordered
Start with patient on left side—instill half of solution—supine—then right lateral side for rest of solution
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Management Cleansing enema
Relief of constipation Empty and cleanse the bowel prior to surgery or
testing Large volume enema—500 to 1,000 ml Small volume enema--<250 ml, usually 90 to 120
ml
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Management Order—enemas til clear
Enemas administered until the expelled solution no longer contains feces and is relatively clear
Within a LIMIT of three 1,000 ml enemas Avoid giving more than 3 large volume enemas
consecutively Cause fatigue and irritation of intestinal lining
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Management Types of solutions
Tap water Normal saline Soapsuds Commercially prepackaged small volume oil or
sodium phosphate solutions
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Management Soapsuds
Castile soap—5 ml/1,000m of solution—no substitutes—other soaps too harsh—damage intestinal lining
Distends intestine and irritates the walls of intestines to further stimulate peristalsis
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Management Tap water
Hypotonic! High risk individuals?
Normal Saline Isotonic
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Management Hypertonic
May be used in small volumes for adults Fleet’s enema Not used in large volume enemas—increased risk
of fluid and electrolyte imbalances Milk and molasses enema—hypertonic—
persistent constipation or impaction removal—follow agency policy
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Management Oil retention
Soften hard stool of an impaction to ease removal Small volume—90 to 120 ml Allow time to soften stool—approx. one hour
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Management Medicating enema
Steroid—decrease inflammation Kayexalate enema—to lower a very high
potassium level Must retain in bowel—solution pulls K+ from
bloodstream into solution to be expelled Follow agency policy
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Management Return flow enemas
Aka Harris flush Remove flatus or gas Tap water or saline Small volume—100 to 200 ml Then lower container below level of rectum—fluid
and gas returned—bubbles—continue til no bubbles—Follow agency policy
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Contraindications Rectal surgery Severe bleeding hemorrhoids Ulcerative colitis or Crohn’s disease Rectal fissure or rectal cancer Excessive bleeding potential due to disease or
medication Certain heart conditions
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Complications Two serious complications
Vagal response Perforation of intestinal wall
Vagus nerve Innervates heart, bronchioles, as well as the
gastrointestinal (GI) tract
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Complications Insertion of the enema tube can stimulate the
vagus nerve When stimulated—can drop the heart rate to
30 to 40 bpm and cause constriction of the bronchioles of the lungs
If continues longer than a few minutes—inadequate blood pressure and circulation
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Complications S/S of vagus nerve stimulation
Chest pain or chest heaviness or pressure Shortness of breath or inability to breathe Dizziness Feel like fainting Nausea Pallor
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Complications S/S of vagus nerve stimulation
Clammy skin Pulse rate <60 bpm
STOP enema or removal of impaction Remove the tube or finger from the rectum Position supine
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Complications Assess pulse rate, skin color, and is patient
diaphoretic? Call for assistance—do not leave patient If pulse <60—place in shock position—head
lower than feet Assess blood pressure Supply oxygen if needed
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Complications Perforation of colon
GENTLY insert tubing Never force Do not insert further than 4 to 6 inches Direct tip of tubing toward umbilicus—follows
natural direction of colon Proper positioning
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Laboratory Tests to Determine the Cause of Bowel Alterations
Guaiac test (occult blood test) Tests for presence of blood in the stool
Culture and sensitivity (C&S) Identifies microorganisms infecting the stool and
the antibiotics that will kill the microorganisms Ova and parasite test (O&P)
Tests for presence of parasitic worms and their eggs
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Collection Clean and dry bedpan or collection container Can not mix specimen with urine Wear gloves Clean tongue blade Collect from 2 different areas of stool—
especially an abnormal appearing areas
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Collection If incontinent collect from depends Properly identify specimen Properly package Specimen sent to lab upon collection Document type of specimen collected,
characteristics, date and time of collection and sent to lab
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Important Read……. Skill 30-1, pg. 698-699 Skill 30-2, pg. 700 Skill 30-3, pg. 701 Skill 30-4, pg. 702
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True/False Question
The nurse administering an enema to a patient knows that the tip of the tubing should be inserted into the rectum while the patient is in a sitting position, as on the toilet.A. TrueB. False
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AnswerB. FalseRationale: The nurse should never attempt insertion of the tip of the tubing into the patient’s rectum while the patient is in a sitting position. The angle of the natural curve of the rectum and sigmoid colon changes when sitting. This can cause the tip of the tubing to scrape the intestinal wall, possibly damaging the mucosal lining, and increases risk of perforating the intestinal wall.
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Multiple Choice Question
A nurse is ordered to administer an enema to a patient to soften an impacted stool. Which type of enema would typically be used?A. Cleansing enemaB. Oil retention enemaC. Medicating enemaD. Return flow enema
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Answer
B. Oil retention enemaRationale: Oil retention enemas are administered to soften the hard stool of an impaction so that it can be removed more easily and with less discomfort for the patient.